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Diabetes patient Jay Littlewolf says he sought medical help for a diabetic ulcer at a Billings hospital after not receiving “adequate health care through the IHS in Lame Deer.” He wants reimbursement from the IHS and sought Sen. Jon Tester’s assistance.Photo/Larry Mayer, Gazette staff

BILLINGS – Montana’s Indian tribes, which until recently thought the Affordable Care Act would pass them by, could face fines exceeding $1 million for not offering insurance to employees.

Beginning in 2016, businesses with 50 or more full-time workers will have to offer at least a minimum amount of health insurance to employees. Those who don’t comply face tax penalties, and that includes tribal governments.

The requirement has been a surprise to tribes, said George Heavy Runner, Blackfeet Insurance Services health and wellness coordinator. As individuals, American Indians have the option of choosing not to follow Affordable Care Act rules. Many assumed tribal governments, which are sovereign, had that same option.

“We thought this was a ship kind of passing us by,” Heavy Runner said. “But it’s not just a ship passing through the night. We have been identified in this legislation, just not where we thought we would be.”

Tax penalties facing the Blackfeet Tribe for not complying could be as high as $1.1 million. Crow Tribal Chairman Darrin Old Coyote said the size of the fee depends on how many people a tribal government employs.

“If we don’t do the mandate, we’re going to be fined for the number of employees we have, and that number could be up to $1.5 million,” Old Coyote said. “We pay federal tax, and our employees pay federal tax and so we’re part of the large employer mandate.”

The tribes can avoid the fees by offering the insurance to their workers. Old Coyote said the Crow have hired a benefits manager to do just that.

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The change caught tribes off-guard because American Indians by treaty receive health care via the Indian Health Service on reservations. IHS is much maligned by tribal members for not providing adequate health care and for not covering services by specialists outside the IHS program.

Because IHS is limited, tribal members who work for their government would benefit from having other health care, Old Coyote said. The challenge is having a health care plan to offer by next year.

Suing to get off the employer mandate has already been tried. In February, Wyoming’s Northern Arapaho Tribe failed to convince a federal judge to block the employer mandate. The Northern Arapaho argued that subjecting tribes to the employer mandate was an oversight that overlooked treaty rights related to Indian health care, while also stating that tax credits and benefits granted to Indians under the Affordable Care Act would be denied.

Earlier this month, U.S. Sen. Steve Daines, R-Mont., and U.S. Rep. Ryan Zinke, R-Mont., announced a bill to exempt tribes from the employer mandate. Daines called the mandate a job killer for tribal governments, who wouldn’t hire as many employees if they had to pay significant penalties.

Other sponsors of the bill, such as Republican Sen. John Thune, of South Dakota, said it was unfair to exempt individual tribal members and not exempt tribal governments as well.

However, exempting tribes from the employer mandate won’t help the nagging problems with Indian health care, said a representative for Sen. Jon Tester, D-Mont.

“This bill does nothing to solve the underlying problem, which is crisis-level health disparities among Native Americans,” said Marnee Banks. “If we are serious about increasing access to quality health care in Indian Country, we will expand Medicaid and adequately fund the Indian Health Service.”

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IHS spending on Indian patients was $2,741 per person in 2013, according to the National Congress of American Indians, which asserts that IHS is severely underfunded. Medicaid spending, by comparison was $5,841.

The state of Montana is awaiting federal approval of the state’s plan to begin offering Medicaid to Montanans earning up to 138 percent of the federal poverty level.

Medicaid expansion would extend benefits to as many as 11,000 tribal members over the next four years, said Jon Ebelt of Montana’s Department of Public Health and Human Services. The program would benefit tribal health care in general, Ebelt said.

“Medicaid expansion revenue will be critical for building health infrastructure, expanding the workforce, and keeping health care providers in tribal communities,” Ebelt said. “Medicaid revenues will bring new funds to the programs and further investment in the Indian health system infrastructure and workforce. This is an opportunity to provide more health care services, create more jobs and employ more Native Americans in tribal communities.”

Old Coyote said he’s concerned that state benefits representatives won’t be able to clearly explain the expanded Medicaid program to some Crow Indians who speak Crow as their primary language. He’s asked the state to provide a benefits representative who is fluent in Crow.

Ebelt said the state is able to provide translation assistance if necessary and in determining an outreach plan with members of the Indian Health Service at Crow Agency.

These days “new” money is hard to find. That’s the kind of money that’s added to a budget, money that allows programs to expand, try out new ideas, and look for ways to make life better. Most government budgets are doing the opposite: Shrinking. Calling on program managers and clients alike to do more with less.

That’s why the news from Alaska last week is so exciting: Alaska’s new governor announced the expansion of Medicaid and this will significantly boost money for the Alaska Native medical system. Indeed, the significance of this announcement to the Indian health system was clear when Gov. Bill Walker and Department of Health and Social Services Commissioner Valerie Davidson made the announcement at the Alaska Native Medical Center on July 16. The governor took this action using executive authority because the Alaska Legislature had failed to even vote on legislation to accept Medicaid.

The governor says Medicaid expansion would reduce state spending by $6.6 million in the first year, and save over $100 million in state general funds in the first six years. “Every day that we fail to act, Alaska loses out on $400,000,” the governor said. “With a nearly $3 billion budget deficit, it would be foolish for us to pass up that kind of boost to Alaska’s economy.”

“We know Gov. Walker has worked tirelessly to expand Medicaid since he came into office on December first,” Davidson said at the news conference. It was one of the campaign promises made by the independent governor. “He included it in the budget. He introduced a bill both in the House and in the Senate side. It was a subject of both special sessions. And, it’s the right thing do do for Alaska.”

The expansion of Medicaid is one of key components of the Affordable Care Act. It’s critical a tool for the Indian Health System because it opens up a revenue channel for clinics and hospitals to bill Medicaid, a third-party insurance, for services. That boosts budgets at the local level, in a political climate where Congress is unlikely to spend more money on Indian health. How big a number? More than a million American Indians and Alaska Natives are now insured by Medicaid. The Kaiser Family Foundation estimated in 2013 that Indian health facilities collected $943 million in third-party payments.

“By far the largest third-party payer is Medicaid, which accounts for $683 million or 70 percent of total third-party revenues, and 13 percent of total IHS program funding for FY2013,” Kaiser reported. Nearly 150,000 Alaska Natives and American Indians receive health services across the state from tribal and nonprofit health organizations funded by the Indian Health Service. By law IHS-funded clinics must seek third-party billing from patients, such as Medicaid, the Veterans Administration or private, employer-based health insurance.

Medicaid is an odd program for Indian country. Most of us understand the IHS to be the government’s fulfillment of its treaty obligations. However the agency has never been fully funded. Medicaid, however, is an unlimited check. If a person is eligible, then the money is there. Yet states, not tribes nor the federal government, determine the rules for Medicaid. And many Republican states have been determined to fight the Affordable Care Act, or “Obamacare,” at every turn, and that means refusing to accept Medicaid expansion (the U.S. Supreme Court ruled in 2012 that states could turn it down).

Alaska’s decision means the number of states rejecting Medicaid is continuing to shrink. Most recently, Montana agreed to expand Medicaid in April. The states with large American Indian and Alaska Native populations that have not expanded Medicaid include Oklahoma, South Dakota, Wisconsin, North Carolina, Maine, Wyoming, and Idaho. Utah is the next state considering an expansion.

The Affordable Care Act continues to evolve — and improve. But more important, steps that states are taking to expand Medicaid are adding real dollars to the Indian health system.

Mark Trahant is an independent journalist and a member of The Shoshone-Bannock Tribes. He served two terms as the Atwood Chair of Journalism at the University of Alaska Anchorage. For updated posts, download the free Trahant Reports smartphone and tablet app.

The views expressed here are the writer’s own and are not necessarily endorsed by Alaska Dispatch News, which welcomes a broad range of viewpoints. To submit a piece for consideration, emailcommentary(at)alaskadispatch.com.

Report highlights the disparity in insurance access among Native communities

A new report from the Alliance for a Just Society, Indian People’s Action, and the Montana Organizing Project suggests that Native Americans may not have as much access to Montana’s health insurance exchange as they should. Approximately 6.5% of Montana’s population is comprised of Native Americans, with an estimated 1.7% of enrollees in the state’s health insurance exchange falling into this demographic. The report highlights barriers that exist in the state that may be preventing Native Americans from receiving medical care.

There are significant barriers blocking Native Americans from the coverage that they need

The report notes that access to insurance coverage does not guarantee quality medical care. According to the report, the delay in expanding the state’s Medicaid program has prevented many people from receiving the care that they need, as a significant portion of consumers cannot afford coverage offered through the state’s health insurance exchange. The report also notes that there has been a significant lack in outreach to Native American consumers, which means that these consumers are not being made aware of the services offered by the state’s insurance exchange.

Efforts are underway to improve access to health insurance

In the earliest days of the state’s insurance exchange, Native American organizations were not provided with grants from the federal government that would pay for insurance navigators. These navigators are meant to assist consumers in enrolling for health insurance coverage through a state exchange. The navigators also provide information concerning the provisions of the Affordable Care Act and can provide some insight on the availability of subsidies being offered by the federal government. Without navigators, Native communities were unable to access the information that these navigators were meant to provide. Now, however, certified application councilors are available to take on the role of navigators.

Expanded Medicaid system may be helpful

Montana is still planning to expand its Medicaid system, but this could take time. Implementing the expansion may ensure that more Native peoples have access to health insurance coverage, but outreach efforts will have to increase if the state wants to ensure that these people are even aware of the expansion. Without outreach, many Native consumers may not know that they are becoming eligible for health insurance through Medicaid.

A federal court in Casper considered blocking an Internal Revenue Service rule that Northern Arapaho officials say could cause Native Americans to pay more for insurance or lose health care benefits.

Tribal leaders say the proposed IRS interpretation of a mandate for large employers to provide health care coverage would unlawfully exempt tribal members who work for the Northern Arapaho from receiving tax credits and cost-sharing benefits granted Native Americans in the Affordable Care Act.

Kelly Rudd, the Northern Arapaho attorney, said the agency’s interpretation could subject the tribe to more than $1.5 million in tax penalties if its business entities, including Wind River Casino, do not offer employer-sponsored insurance.

Two dancers in regalia work a Native American Professional Parent Resources outreach booth at the 2014 Gathering of Nations powwow in Albuquerque, N.M. | Courtesy Photo

OKLAHOMA CITY – Despite living in a state where Medicaid was not expanded, Oklahoma’s 38 federally recognized tribes have found a way to state tribal liaison, Sally Carter – and she has found her way to them. In this newly created position, Carter is quick to tell you that she considers Oklahoma to have 39 tribes because even though the Euchee are not federally recognized, they are state recognized. Breathlessly, she says she is learning fast.

“I still count them,” she said.

Carter carries Euchee concerns on health matters back to the state capital as part of a new stance where the health decision makers seek to repair a long and tenuous relationship between historical archetypes. When the Affordable Care Act (ACA) was passed in 2010, a series of listening sessions between Oklahoma and the tribes occurred at six different tribal jurisdictions across the state to talk about the federal health overhaul. Replete with opening ceremonies and songs, the state was figuratively stretching its hand toward its Native inhabitants.

From these beginnings, Carter takes the message back to the capital that the tribes want to be at the decision-making table with state leaders, including the newly re-elected Republican governor, Mary Fallin.

Carter said the tribes don’t just want to be told about important developments, they want to help shape the direction the state will take on things such as the implementation of the ACA and how to reduce health disparities like high smoking and diabetes rates in their nations.

To date, 1,638 American Indians in Oklahoma have enrolled for federal health insurance through ACA while 13,061 have enrolled nationally, according to a U.S. Department of Health and Human Services (HHS) report. When compared to the 9.1 million estimated Obamacare enrollees, American Indians number roughly 1 percent of all Americans who now have health insurance who had none before.

But that thing that makes Oklahoma’s Indian Country so different—that thing that separates it from other U.S. states with tribes – is that it has no official Indian reservations. A federal land allotment experiment from the 1900s crisscrossed the state’s territory into a veritable smorgasbord of jurisdictions – federal, tribal, municipal, state.

Carter is working on how to stimulate enrollment among Oklahoma tribes.

If the government wants to reach the American Indians here, it’s best to go to each tribe, Carter said. That was a go-to move state health officials embraced as they discussed ACA with the tribes. The things Carter found surprised her although she is an Oklahoma resident and had lived near various tribal jurisdictions for years.

“They are the only (minority) group that has to show their race,” she said, her voice lilting. “I mean, no other group has to do that. They have to prove it with an enrollment card of some kind.”

Official American Indian citizenship is important because the ACA has special provisions that allow Indians to “opt out” of having to enroll in federal health insurance, if they choose. But Indians need to fill out form OMB No. 0938-1190 that officially removes them, officials said. Not doing so will mean an eventual penalty.

“(ACA) is very complex and not one of us would say that we know it all,” Carter said. So the state took the best of what they knew after weeks of training on the health plan to several tribal jurisdictions. When all sides met, Carter said she was schooled. American Indians have strong opinions about the state/ federal government encroaching on their personal privacy and tribal sovereignty with this new federal health insurance.

Because Oklahoma chose not to expand Medicaid, enrolling American Indians in ACA takes a certain degree of cultural finesse and dogged persistence, Carter said. In other tribally populated states, like North Dakota, the move to expand Medicaid fills in where ACA may not be a strong priority, said Sen. Heidi Heitkamp, D-ND. The emphasis is reducing uninsured numbers, she said.

“The State of North Dakota expanded Medicaid, which has helped uninsured, low-income individuals and families, including many Native Americans throughout the state, get access to affordable health care,” Heitkamp said. “ Medicaid expansion is giving families opportunities they didn’t have before to afford to see a doctor regularly and get access to needed medications, while reducing costs for everyone – those with health coverage and those without.”

The Oklahoma tribal liaison added that even while enrollment curiosity abounded, many did not qualify for ACA because they did not file income tax returns. American Indians can enroll in ACA at any time – not just during enrollment periods, but their tax filings allow them also to file the exemption – if they chose to forgo coverage.

American Indians have a higher unemployment rate than other groups–peaking in 2013, according to the Bureau of Labor Statistics Current Population survey. Indian unemployment rates averaged 11.3 percent compared to 9.1 percent of the mainstream during that time. High unemployment rates among Indians tend to keep more Indians ineligible for ACA enrollment, Carter said.

What has also dampened Oklahoma’s outreach has been a distrustful relationship between the state and tribes—this makes it harder for federal initiatives to come through the front door, said Terry Cline, Oklahoma’s commissioner of health. He points to the good faith of the tribal/state meetings.

“I considered the listening sessions a good start,” he said. An official summary on the sessions reported 193 attendees at the six sessions, several of which Cline attended.

“We held those sessions to have open dialogue,” he said. “What you hear from one tribe might be different from another tribe says.”

As for ACA and tribes, a tribe’s type of relationship with the federal government, either Self-Governance or direct service, dictated outreach approaches because that’s how health dollars are administered by tribes in states, especially in Oklahoma, officials said.

Tribes that operate under provisions of the Indian Self Determination Act might outreach on ACA directly to members in their own tribally run health systems and tribes that are direct service entities may forgo outreach to their local Indian Health Service (IHS) service facility. In both regions, IHS and tribal facilities can accept ACA insurance from patients and lessen the amount of contract (out-of-IHS system) health dollars it spends, officials said.

“Tribes have a lot of interest in ACA,” Carter said. “Tribal leaders and the health department can inspire and direct tribal members to enroll.”

Both of the tribal-to-federal relationships are considered when the state of Oklahoma contacts tribes, and the state tends to follow the federal approach, Carter said. Putting on different hats to deal with different tribes is prudent.

“Tribes need to see people they know and that they can trust who know about American Indian provisions,” she said. “I believe in face-to-face interactions. States usually contact them (tribes) with emails or letters, but a relationship needs to be worked on and allowed to develop.”

Cline said no special state appropriations exist to outreach to tribes for ACA enrollment in Oklahoma but he’s optimistic that other types of federal grants to reduce health disparities will help. The health commissioner said he knows Oklahoma has room for ACA Native growth through grants.

The HHS report points out that Oklahoma has the highest density of Indians among Federally Facilitated Marketplace (FFM) states with 3.5 percent of the population followed by Wyoming, with 3.1 percent. Wyoming’s total Native ACA enrollment stands at 309, the report shows.

At this point, Oklahoma seems to lead the state in the number of Natives it has enrolled, just exceeding figures for California. But as enrollment rolls on, officials expect more American Indians to register. Indian Country (the term used to characterize where a federal-tribal relationship exists) extends beyond Oklahoma.

Other states with significant Native populations include Arizona, California, New Mexico, South Dakota and North Dakota. ACA data gathering for Native numbers is in its infancy, organizers said. They say the goal is to pool their information from various regions (via Indian advocacy agencies) to get a more precise picture of Native ACA enrollment. Due to their smaller population numbers, American Indian statistics are often overlooked, officials said.

Other mainstream entities who track the progress are unclear about just how many have actually signed up for ACA. Michelle McEvoy, vice-president of survey, research and evaluation for the Commonwealth Fund, said that no Native specific information has been garnered by her group.

“Latinos currently represent about 17 percent of the U.S. population, so they have a greater probability of being sampled than American Indians who represent about 1.2 percent of the U.S. population,” she said.

“We do work with partners at the local level to reach different communities, like Native American groups in certain parts of the country,” McCarron stated. “We work with a few partners who have made outreach to tribal communities a high priority.”

Meanwhile, Carter is optimistic about ACA enrollment and reaching American Indians in Oklahoma.

“(ACA) is bigger than all of us,” she said. “We can’t do this alone; it only happens when the state extends its hands across the table and says we need to do this for all the people.”

– This story was funded by the University of Southern California’s (USC) Annenberg School of Journalism as one project undertaken by the 2014 class of California Endowment Health Journalism Fellows. S.E. Ruckman is writing a three-part series on the Affordable Care Act (ACA) in Indian country. In addition to mainstream viewpoints, American Indian health advocates and American Indian enrollees are visited to gauge the national health plan’s implementation in Native populations. Fellows’ projects can be found at www.reportingonhealth.org.

Kauffman & Associates, Inc., an American Indian-owned communications and professional services firm, has won the 2014 National Health Information Award for its 2-year national campaign encouraging American Indians and Alaska Natives to sign up for health insurance under the Affordable Care Act. Other 2014 award winners include the American Association of Retired Persons, American Lung Association, Parents Magazine and the Mayo Clinic. The National Health Information Awards program honors high-quality consumer health information. The awards program is organized by the Health Information Resource Center, a national clearinghouse for consumer health professionals who work in consumer health education fields.

Working with its client, the Centers for Medicare and Medicaid Services’ (CMS) Tribal Affairs Group, KAI tested messages and images with American Indian and Alaska Native stakeholders throughout the United States and created radio spots, videos, billboards, bus signs, brochures, fact sheets and social media spots. KAI also recruited partner organizations from across the country and conducted outreach at large powwows, conferences, summits and sports events. KAI Vice President for Communications, Kim Blessing, reported “the campaign generated more than 100 million media impressions, recruited 113 tribal and organizational partners and distributed 23,000 informational brochures”.

“American Indian and Alaska Native people finally have the opportunity to ensure their health needs are fully covered, but they have to sign up. This is so important. It was a privilege to help CMS with this campaign,” said KAI President Jo Ann Kauffman, a public health professional and member of the Nez Perce Tribe.

The campaign also included a 7-minute video featuring former CBS News reporter Hattie Kauffman. This video, directed by Josephine Keefe, won the 2014 Telly Award earlier this year. The video is available online and is currently being played in Indian health clinic waiting rooms across the nation. Monthly radio public service announcements (PSA) were also produced by KAI, and featured both English and Native language speakers. Radio PSAs were sent to Native radios each month on topics about special benefits and protections for American Indians and Alaska Natives. These PSAs were recorded in English, Navajo, Lakota, Ojibwe and Yupik. Companion “drop-in” articles were placed in Native newspapers to reinforce the radio messages.

KAI has provided research and communications support to federal agencies, tribes, nonprofits and foundations in the area of public health, education, justice and community development since 1990.

Most Americans are supposed to have health insurance under the Affordable Care Act. But up to 50,000 Alaska Natives and American Indians in Alaska are excused from the requirement. They have to apply for that lifetime exemption though. And the federal government is mishandling many of those applications.

The form Alaska Natives and American Indians need to fill out to get an exemption from the individual mandate.

Evelyn Burdick thought it would be easy to apply for her American Indian exemption. As a member of the Cherokee Nation, the Anchorage resident sees a doctor at the Alaska Native Medical Center. Burdick likes the care she gets there and has no plans to sign up for private insurance under Obamacare. So she sent an exemption application to the federal government almost as soon as it was available, on January 9th:

“I have yet to receive any correspondence from them back whatsoever. Not even to let me know they’ve received my application.”

Burdick is not alone. The Alaska Native Tribal Health Consortium has helped hundreds of Alaska Natives and American Indians in the state who have had problems with their exemption applications. The exemption is a simple six digit number applicants need for their tax forms to avoid paying a penalty ($95 dollars or 1% of income, whichever is greater) for not having health insurance. Monique Martin, with ANTHC, has been working with the federal government to resolve the problems:

“Every time we call it’s a bear with us sort of request but we’ve been bearing with them since February when we first started reporting issues and we are anxious for a resolution to this issue.”

The Federal government has fumbled the applications in several different ways. Martin works closely with three other people at ANTHC who all applied for the exemption for themselves. Martin’s exemption number came back with no problems. But her three colleagues were not so lucky:

“One of our coworkers received her letter twice, with two different exemption numbers for her and her kids. One received the wrong exemption… and another one is still waiting to hear on her application. So we’ve seen all the errors come to us, so we have real world examples that we can show the federal government.”

No one from the Centers for Medicare and Medicaid Services was willing to do an interview for this story. In an e-mail, a spokesperson with the agency wrote that they are working to improve the process daily and committed to providing consumers with their exemption numbers in time for tax filing season. Martin says she’s cautiously optimistic that can happen:

“We are the squeaky wheel in Alaska and we’re really pushing the federal government to resolve this issue and to get this addressed for people so they aren’t negatively impacted.”

Martin worries about how the federal government will handle the rush of exemption applications as tax time approaches. She expects many Alaska Natives and American Indians haven’t even thought about sending in the application yet. Evelyn Burdick, who was proactive and applied early in the process, says the nine month long wait for a response has been frustrating:

“I don’t want to be penalized for not having the healthcare.gov insurance. I’m trying to follow the rules and regulations that healthcare.gov set up and they’re not making it any easier.”

Late last month, Monique Martin was able to get Burdick’s exemption number for her from a contact at the federal government. Burdick is happy to have the number, but she still wants to see it in writing. She says she has no idea when it will arrive in her mailbox, but at this rate she’s not expecting it any time soon.

This story is part of a reporting partnership between APRN, NPR and Kaiser Health News.

“We don’t want to just train technicians — we want to train healers,” Alan Shelton, the clinical director for the tribe’s authority, told McClatchy News. “And the way we train healers is we connect them to the Native American community and they learn about ideas of wellness and spirituality. And when they connect with patients, they connect with them on a deep level.”

The Puyallup Tribe was the first in Indian Country to utlize program. The Choctaw Nation of Oklahoma is the second and more tribes could join if Congress authorizes an extension.

“[W]e’re actually training doctors in rural settings or tribal settings so that they will then be employed there, where we have the highest need,” Sen. Patty Murray (D-Washington), who has introduced the Community-Based Medical Education Act to keep the program running through 2019, told McClatchy.

In this July 10, 2014 photo, Denise Mesteth poses outside the powwow grounds in Pine Ridge, S.D. Mesteth is a member of the Oglala Sioux Tribe, born and raised on the Pine Ridge reservation. She has signed up for health insurance through the federal marketplace. (AP Photo/Nora Hertel)

By NORA HERTEL Associated Press

PINE RIDGE, South Dakota — Denise Mesteth signed up for new health insurance through the federal Affordable Care Act, despite concerns that it may not be worth the money for her and other Native Americans who otherwise rely on free government coverage.

Mesteth, who has a heart murmur and requires medication and regular blood work, said she’s cautiously optimistic that the federal insurance will be superior to what she has now. Many other American Indians have been more reluctant to enroll, choosing instead to continue relying on the Indian Health Service for their coverage and taking advantage of a clause in the federal health reform law that allows them to be exempt from the insurance mandate if they meet certain requirements.

“If it’s better services, then I’m OK,” Masteth said of ACA. “But it better be better.”

Mesteth and other American Indians in South Dakota account for 2.5 percent of the people in the state who have signed up for insurance under the federal health care law, according to the latest signup numbers. The state, with nearly 9 percent of its overall population Native American, ranks third for the percentage of enrollees who are American Indian among U.S. states using the federal marketplace.

The Great Plains Tribal Chairmen’s Health Board, which provides support and health care advocacy to tribes, received $264,000 to help Native Americans in South Dakota navigate the new insurance marketplace.

Tinka Duran, program coordinator for the board, said people are primarily concerned about the costs of enrolling. Insurance is a new concept to most because health care has always been free, she said.

“There’s a learning curve for figuring out co-pays and deductibles,” she said.

During a U.S. Senate Indian Affairs Committee hearing in May, tribal leaders chastised IHS as a bloated bureaucracy unable to fulfill its core duty of providing health care for more than 2 million Native Americans and Alaska Natives. IHS acting director Yvette Roubideaux said changes were underway but that more money will be needed than the $4.4 billion the agency receives each year.

She noted that federal health care spending on Native Americans lags far behind spending on other groups such as federal employees, who receive almost twice as much on a per-capita basis. Meanwhile, American Indians suffer from higher rates of substance abuse, assault, diabetes and a slew of other ailments compared to most of the population.

Native Americans and Alaska Natives are exempt from the health insurance mandate if they meet certain requirements. ACA also permanently reauthorized the Indian Health Care Improvement Act and authorized new programs for IHS, which also is starting to get funds from the Veterans Affairs Department to help native veterans.

When American Indians do obtain insurance, it means fewer people are tapping the IHS budget, said Raho Ortiz, director of the IHS Division of Business Office Enhancement.

“If more of our patients have health insurance or are enrolled in Medicaid, this means that more resources are available locally for all of our patients,” Ortiz said in an emailed statement. “This, in turn, allows scarce resources to be stretched further.”

Those who sign up for federal health care can still use IHS facilities but have the option of seeking health care elsewhere, Ortiz said.

State Democratic Sen. Jim Bradford is among the skeptics. The Oglala Sioux member lives on the Pine Ridge reservation, home to two of the poorest counties in the nation.

The U.S. government provides health care to Native Americans as part of its trust responsibility to tribes that gave up their land when the country was being formed. Bradford and others object to the shift in health care providers on the principle that IHS is obligated by treaty to supply that care.

Harriett Jennesse, a member of the Lower Brule Sioux Tribe who lives in Rapid City, said she already has seen the benefits of the new health insurance and doesn’t mind paying a little out of pocket.

Jennesse said she put off treatment for a painful bone chip in her elbow after IHS denied a doctor’s referral to a specialist on grounds that it wasn’t an urgent enough need. She’s now seeing a specialist for dislocation in her other elbow and will also try to get the bone chip fixed when the other arm heals.

The Affordable Care Act (ACA), signed into law in 2010, became effective January 2014. Many questions continue to roil in the minds of American Indians about just what the new health care law means to them.

The law helps make health insurance coverage more affordable and accessible for millions of Americans, including American Indians. Importantly, the law addresses inequities, increases access to affordable health coverage and prevention medicine for tribal members. The ACA is important to American Indians because it provides greater access to care and coverage unmet by the Indian Health Service (IHS).

The ACA requires all Americans to have health care insurance coverage. However, American Indians and Alaska Natives have the option to file a lifetime exemption. They are encouraged by the state Health Care Exchange to file the exemption regardless of their current insurance status in case their insurance should ever lapse.

There are numerous state and federal agencies working to implement and manage ACA health care delivery. Tulalip members can most directly obtain enrollment process advice from clinic staff members who have received specialized training as Tribal Assisters. They can help members through the enrollment process and refer you to a broker who is licensed to provide information and advice on qualified health insurance plans and policies. Tulalip Resource Advocate, Rose Iukes, has received intensive training on the ACA. She and Brent Case can answer questions and help enroll members. Fortunately, for Tulalip members, the Board of Directors contracted with a licensed broker, Jerry Lyons, to assist members in understanding and selecting the best-qualified health insurance plan for themselves.

Asked about the greatest impediment to enrolling tribal members, Rose Iukes said many tribal members assume IHS coverage is sufficient, so have been disinterested in the ACA. Even so, she noted, “We had almost 800 people apply. We got probably about 250 on qualified health plans and about 150-180 on Apple.” She said efforts were hampered by the state system “going down,” which required many tribal enrollments to be done in-person. “There were so many flaws that we started having people do paper applications here at the clinic. Now, we need to have them do follow-up. We didn’t get to do a test-run on the site. We thought we could go in and enroll them, but there were additional security questions. So, now we’re asking members who completed paper applications to come in and complete their application processes.”

Even with the challenges, Washington State fared better with its overall ACA rollout than other states, leading the nation in early enrollment numbers.

Rose Iukes noted significant confusion due to the state’s failure to provide clarifying information on special tribal provisions and exemptions on its websites and call centers. She said, “I’m hoping these call centers get educated on the tribal provisions and exemptions.” She could not say why there is little detail about income, age and other special provisions posted on state websites. Publicizing details of special federal poverty level provisions and exemptions for tribal members may be confusing to the general public. The result is that the rollout for American Indians, especially urban Indians without easy access or even referral to a Tribal Assister, has been challenging. However, despite the state’s system inadequacies, Iukes praised the American Indian Health Care Commission staff and Sheryl Lowe at the Washington Health Care Exchange whose support she felt was invaluable.

“The bottom line for tribal members, if they have ACA health care they can be taken care of. And they can get the help they need. That’s what drives me and why I advocate the way, I do. I don’t want somebody to go through the heartache,” said Iukes.

Tribal members often inquire about alcohol and chemical dependency treatment options, especially as many have a history of unsuccessful treatment attempts. Iukes said that beyond the Tribe’s one treatment option, “With qualified health plans, there is unlimited treatment, but we need to find a way to help them pay their premium. For example, a young man was ready to go to treatment, but his premium was $4. It must be paid with a debit card, but he didn’t have one. Ultimately, he didn’t go to treatment. I’ve asked the Board about setting up a way for the premium to come out of per capita, then we can issue them a card to use” to pay their premiums.

Broker, Jerry Lyons, is licensed with eighty (80) different insurance companies said, “In my brief time working with Tulalip, we feel confident in our efforts. We are being successful as we have been instrumental in assisting members with questions and we have enrolled more Native Americans into the ACA than any other tribe.” He added that never in his career has he been involved in a more “disorganized” insurance roll-out, but emphasized it was not due to the tribal efforts, but rather the bureaucracy. “Even so, we have helped about 250 people obtain insurance in one way or another.” Asked if he is available to all members many of whom reside off-reservation, Lyons replied, “We assist all members. There are also many special plans that most tribes are unaware of. Just have them call me.”

Several state, public/private, federal, and non-profit organizations are supporting tribal ACA implementation and enrollment. They are the Washington Health Benefit Exchange, the Health Care Authority, the Centers for Medicare and Medicaid Services (CMS) Region 10 office in Seattle, and the American Indian Health Commission.

Washington Health Benefit Exchange (HBE)

The Washington Health Benefit Exchange was created in 2011 state law as a “public-private partnership” separate and distinct from the state. The Exchange is responsible for the creation of Washington Healthplanfinder–the online marketplace to assist Washingtonians to find, compare, and enroll in qualified health insurance plans.

Many tribal members who rely upon IHS for their health care needs question the need to apply for ACA coverage. They also question the need to go outside treaty guaranteed health care services. Unfortunately, as most trust responsibilities, health care for American Indians/Alaska Natives has been historically and woefully underfunded and continues to be so today.

When asked why the ACA is important to tribal members, Sheryl Lowe, tribal liaison with the Washington Health Benefit Exchange, said, “Individual coverage offers tribal members more access to specialty care and even if the member uses their own tribal clinic, the tribe can then bill the health insurance company rather than the Indian Health Service. She emphasized that the basic tribal contract dollars can then be utilized for other urgent and uncovered care.

Lowe said the ACA benefits both individuals and tribes. “For most tribes, IHS only provides direct care and tribes have to pay Contract Health Care. And the IHS continues to be funded at less than fifty percent of need, so the ACA is another way for individuals and tribes to access health care. Also, most tribal clinics are Priority One clinics offering basic care and provide referrals only for life and limb.”

After working out many of the bugs and training, there are 93 Tribal Assisters, at least one in each of the federally recognized tribes in Washington, the state and the Tribal Assisters are now able to focus upon a more comprehensive effort to enroll tribal members. Lowe praised the Tribal Assisters who she credits with outstanding efforts to learn a complicated enrollment process to become certified as Tribal Assisters. She said Tulalip has four Tribal Assisters and she exclaimed, “Rose Iukes is so dedicated!” The HBE shared the following statewide training statistics:

The Health Benefit Exchange reports that statewide, of the 26,378 who answered “yes” to “Are you an American Indian/Alaska Native [AI/AN]?” on the ACA enrollment site, 21,201 of “enrolled tribal members” have enrolled in the Healthplanfinder. Significantly, 17,350 enrolled in Washington Apple Health (expanded Medicaid). Unfortunately, of the 3,885 AI/ANs eligible for Qualified Health Plans, only 1,110 actually enrolled even though many would likely have zero to low premiums and no cost shares.

Lowe said she couldn’t emphasize enough the importance of tribal members considering enrollment because those whose income falls in 138 – 300 percent of federal poverty level have no cost-sharing which means no co-pay or deductibles, “which is a huge benefit.” She added, “Depending upon household size and other factors, some may even have a premium that is zero. They can take the tax credit to lower their monthly premium or take it at the end of the year. Those in the 138 – 400% of poverty level are eligible for premium tax credits. Depending upon income or household size you can get tax credits which will reduce your overall costs.” She pointed out that some plans have deductibles for $5000 for a family before they’ll pay anything, so the cost-sharing benefit is one of the biggest things for tribal members.” It is clearly worthwhile for tribal members to speak to a tribal assister and/or broker.

Those whose income is below 100 – 138 percent of federal poverty level qualify for expanded Medicaid or Apple Health as it is now called. However, children are eligible for Apple Health in households whose income is up to 300% of the federal poverty level. Therefore, although the adults may not qualify for Apple Health, it is important to consider that children may.

Unlike Apple Health, the Qualified Health Plans do not provide dental. Yet, the ACA does require that all children be covered by dental insurance. The HBE indicates there are two low-cost children’s plans available. Sheryl Lowe indicates there is also discussion about the potential of adult dental plans to be introduced in 2016. Broker, Jerry Lyons, encourages tribal members to ask him about low-cost and special plans that most tribes are unaware.

Washington Health Care Authority (HCA)

The HCA oversees Washington expanded Medicaid or Apple Health plan for low-income residents. Washington is one of 27 states implementing expanded Medicaid. Of the many benefits for American Indians from the new health care law, expanded Medicaid seems most significant. Eligibility for Apple Health (expanded Medicaid) is the same for tribal members and the general public–that is household income below 100 – 138 percent of the federal poverty level. Tribal members in the Apple Health Program would not be eligible for tax credit that is offered tribal members in the Qualified Health Plans. However, one important benefit is that effective January; dental coverage for adults was restored.

Through expanded Medicaid in Washington, countless low-income American Indians and Alaska Natives can now receive specialty care. As of March 25, 2014, of all who identified as AI/ANs at enrollment, 17,350 have enrolled in Washington Apple Health (or expanded Medicaid). Staff at the Tulalip Tribes health clinic is working to update Tulalip enrollment numbers. Rose Iukes reported it is difficult because many are in process of updating enrollment after the glitches in the state system caused the Tribe to revert to paper applications.

Tribal members can enroll monthly by the 23rd, and then the plan starts the first of next month.

Big changes in Medicaid/Apple Health became effective January 2014. Because of the ACA, more people are able to get preventive care, like check-ups and cancer screenings, treatment for diabetes and high blood pressure, and many other health care services they need to stay healthy.

Apple Health (Medicaid) Benefit Changes Effective January 2014

Dental Services for Adults: Dental health benefits were restored for individuals 21 years of age and older in January. Ensure that your dentist is enrolled as a Medicaid provider.

Mental Health Services Unlimited Number of Visits: Beginning in 2014, there are no limits on the number of visits for mental health services in a calendar year.

Expanded Pool of Licensed Providers: Previously, psychiatrists were the sole mental health provider approved for adults, but effective January 2014, mental health services can be sought from a variety of providers. Coverage is expanded to services by Licensed Advanced Social Workers, Licensed Independent Social Workers, Licensed Mental Health Counselors, Licensed Marriage and Family Therapists and Psychologists. Just ensure your provider is enrolled with Medicaid.

Preventative Care Shingles Vaccine: Beginning January 2014, Apple Health shall will cover the shingles vaccination for clients 60 years of age and older. Age 60 or older is considered the most effective time to receive the vaccine.

Early Intervention Screening for Substance Abuse: Apple Health will cover services provided by trained, certified medical providers who conduct screening, brief intervention, and referral for treatment for individuals who may present as facing challenges with substance abuse, including alcohol, drugs and tobacco.

Screening of Children for Autism: Funding has been approved so that Apple Health’s enrolled primary care physicians can screen your child, if they are under three years of age to assess for autism.

Licensed Naturopathic Physicians serving as Primary Care Doctors: Beginning in 2014, licensed naturopathic physicians are able to provide primary care services. Given there are a limited number of primary care physicians, individuals possessing a Washington Department of Health Naturopathic Physician license shall be able to provide care in the scope of care outlined by Department of Health, including diagnosing, administering vaccines and immunizations, provide referrals to specialists, conduct minor office procedures, and write limited Food and Drug Administration-approved prescriptions.

The federal CMS has a Region 10 office to assist tribes with questions about expanded Medicaid and Medicare services. They were unable to be reached for comment. Per the CMS website statement, “Within the vast reforms in PPACA, AI/AN populations will be affected not only by the general provisions, but through specific, explicit provisions, including the permanent reauthorization of the Indian Health Care Improvement Act.”

A question unanswered by both CMS and IHS is how the federal trust responsibility intersects with tribal elders no longer qualifying for expanded Medicaid or Apple Health once they reach age 65. The Washington Health Benefit Exchange is attempting to secure answers to the inquiry. Ideally, those elders would be covered by treaty guaranteed programs created through IHS in their federal trust responsibility and expanded Medicaid that continues beyond age 65.

Though the IHS did not respond to questions about its continuing federal trust responsibility for tribal health care, according to its website, IHS states “it will continue to provide quality, culturally appropriate services to eligible American Indians and Alaska Natives.” Both the CMS and IHS websites also point to the ACA as benefiting Indian elders with strengthened Medicare, affordable prescriptions, and free preventive services regardless of their provider.

The IHS website notes that if tribal members buy private insurance in the Health Insurance Marketplace, they will not have to pay out-of-pocket costs like deductibles, copayments, and coinsurance if their “income is up to around $70,650 for a family of 4.” The IHS assures members of federally recognized they are eligible to continue receiving services from the Indian Health Service, tribal health programs, or urban Indian health programs even if they have obtained insurance in the marketplace.

The Native American Contact (NAC) for CMS Region 10 is Deborah Sosa. Deb is the agency’s main contact for questions or clarification on:

health policies related to the Medicare, Medicaid, and CHIP programs

policies and programs under the Affordable Care Act, such as the new health insurance exchanges/marketplaces, and

emerging health policies and issues that arise in your community.

She can be reached directly at Deborah.Sosa@cms.hhs.gov or by telephone at (206) 615-2267.

Basic ACA Details for Tribal Members

Exemption

American Indian and Alaska Native consumers who are members of federally recognized tribes have access to a Tribal Membership Exemption from the shared responsibility requirement payment. The exemption applies to American Indian and Alaska Natives who are members of federally recognized tribes and are unable to maintain minimum essential coverage for any time during the year.
To receive an exemption, members may apply through the Marketplace, through their tax return submitted to the Internal Revenue Service by April 2015, or members can receive assistance from either Rose Iukes or Brent Case whose contact information is provided earlier in this story. Alternatively, members can access the form at the following website: http://marketplace.cms.gov/getofficialresources/publications-and-articles/tribal-exemption.pdf

If you have health insurance coverage from your employer or if you have other health care coverage (through Medicare, Medicaid, CHIP, VA Health Benefits, or TRICARE), you are covered and don’t need to worry about paying the shared responsibility payment or enrolling for health coverage available through the Health Insurance Marketplace. However, tribal members are encouraged to complete the tribal lifetime exemption regardless of current coverage.

Enrollment

A frequent question arises about enrollment periods. There is no enrollment period or deadline for members of federally recognized tribes and Alaska Native shareholders who can enroll in Marketplace coverage any time of year. Plans can be changed as often as once per month. Be sure to apply no later than the 23rd of the month for benefits to become effective on the first of the following month. Again, see Rose Iukes at the clinic for assistance. Otherwise, information can also be found at the Health Benefit Exchange – Health Plan Finder website: https://www.wahealthplanfinder.org

Insurance Premiums

Premium payment is due by the 23rd of each month for coverage beginning the following month. Payment can be made by echeck or debit card. Recurring payments can only be setup by echeck. Autopay requires an email address. Rose Iukes can assist you with this during enrollment.

Urban Tulalip Tribal Members

The Health Care Authority tribal liaison, Karol Dixon, recommends that enrolled Tulalip tribal members who reside off-reservation, but within Washington state, can access enrollment assistance by telephoning the Tribal Assister at their tribal clinic (Rose Iukes), but if it is more convenient–they can enroll through the HCA website. In fact, all tribal members can enroll there if they choose. At the website, they can locate a Navigator or Broker who can assist them with the process and in selecting a plan. Select the question mark in the top right of the web page to see links to Navigator or Broker at: https://www.wahealthplanfinder.org

Unfortunately, Tulalip members residing outside of Washington are not eligible to enroll through the Washington Healthcare Exchange. They will need to enroll in the state in which they reside. This is disappointing for any members who may be residing in one of the 24 states that have not expanded Medicaid.

Summary

Many American Indians/Alaska Natives are taking advantage of expanded Medicaid as demonstrated by enrollment data reported by the Health Care Exchange. However, enrollment in the Qualified Health Plans, which offer tribal members many tax credits and cost-share exemptions, could be improved. Moreover, the ACA offers American Indians many advantages expanded access and coverage in both Apple Health and the Qualified Health Plans.

Some political and policy questions remain unanswered such as the federal trust responsibility and how that extends to care for tribal elders 65 and over who have no Medicare coverage. One would hope that the ACA’s permanent reauthorization of the Indian Health Care Improvement Act, extending and authorizing new programs and services within the IHS will find a means to address that void in care for our dear elders.

Early enrollment reports from the Health Care Exchange indicate American Indians/Alaska Natives have taken advantage of expanded Medicaid in Washington State. Many of those tribal members were urban Indians who formerly had little access to any health care, so the ACA is proving itself critical to the health services of urban Indians. Those same individuals can also now receive what for many is urgent dental care.

From early indications, the ACA is fulfilling some of its promise in that it is reducing the number of uninsured Americans with more than 8 million Americans enrolling to date. And the number (17,350) of AI/AN enrolled in Washington’s Apple Health (Medicaid) plan as of March 25 seems to indicate the ACA is fulfilling some of its promise to low-income AI/AN and children. Increased tribal enrollment in the marketplace and in expanded Medicaid will free IHS tribal contract dollars for the tribe to utilize for other urgent care needs.

Many political and policy questions remain unanswered relative to trust responsibility and treaty guaranteed expectations. The possibilities of tribal sponsorship have not yet been fully explored. However, in Washington, and at Tulalip, there is a determined effort by many dedicated individuals and organizations to right some of the historic federal oversights in Indian health care.

Kyle Taylor Lucas is a freelance journalist and speaker. She is a member of The Tulalip Tribes and can be reached at KyleTaylorLucas@msn.com / Linkedin: http://www.linkedin.com/in/kyletaylorlucas